Author Archives: Jason Schwartz

About Jason Schwartz

Jason Schwartz, LMSW, ACSW, CADC, CCS, is the Clinical Director of Dawn Farm, overseeing treatment services for its two residential treatment sites, sub-acute detox, outpatient treatment services & detention-based juvenile treatment program. Jason is also an adjunct faculty at Eastern Michigan University’s School of Social Work and School of Leadership and Counseling. Jason blogs at www.addictionrecoverynews.com and has been published in Addiction Professional magazine and in a monograph Recovery-oriented Supervision with the Addiction Technology Transfer Center. Jason serves on the advisory boards of Eastern Michigan University’s School of Social Work and School of Leadership and Counseling. Jason also serves as a board member for the Livonia Save Our Youth Task Force, a substance abuse prevention coalition in his home community.

“not all marijuana users are of equal concern to us”

colorado

Keith Humphreys imagines the reactions of various stakeholders to this graph showing marijuana consumption Colorado.

  • He imagines public health workers expressing concern about the bottom two bars and trying to promote policies that will reduce the amount these heavy users consume.
  • Next, he imagines a corporate board room voicing interest in attracting users in the bottom two bars to their brand and finding ways to retain them.
  • Finally, he puts us in the legislature, which is torn between improving public health and the tax revenue these heavy users provide.

He adds that this illustrates that there is no such thing as value-free policy.

 

 

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1 in 8 deaths among Ontario young adults were attributable to opioids

CanadaA study of opioid-related deaths in Ontario was recently published. There were some really stunning findings.

First, over 20 years, the opioid-related death rate increased by 242%.

During the 20-year study period, we identified 5935 people whose deaths were opioid-related in Ontario. The median age at death was 42 years (interquartile range 34–50 years), 64.4% (n = 3822) of decedents were men and 90.0% (n = 5340) lived in an urban neighborhood. During the study period, rates of opioid-related death increased dramatically, rising 242% from 12.2 deaths per million in 1991 (127 deaths annually) to 41.6 deaths per million in 2010 (550 deaths annually; Figure 1).

Second, young adults have been hit especially hard. [emphasis mine]

The highest absolute increase occurred among individuals aged 25–34 years, in whom the proportion of deaths related to opioids increased from 3.3% in 1992 to 12.1% in 2010.

. . .

The finding that one in eight deaths among young adults were attributable to opioids underlines the urgent need for a change in perception regarding the safety of these medications.

 

When we see these kinds of statistics in the US, we’re left to wonder the role that poor treatment access played.

We conducted a serial cross-sectional study of all opioid-related deaths in Ontario, Canada between 1 January 1991 and 31 December 2010. Ontario is Canada’s largest province, with more than 13.2 million residents in 2010, all of whom have access to publicly funded health insurance for physician and hospital services.

I don’t know much about the kind of treatment that’s been available to Ontario addicts. It’d be interesting to learn more about that.

 

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Radical Recovery

This week’s Throwback Sunday is Bill White’s description of radical recovery.

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Be-The-Change-e1348837935700For MLK day, here’s an article by Bill White on “radical recovery.” He describes a convergence of social activism and addiction recovery.

The article offers a model that goes well beyond the the interests of recovering people themselves and encourages advocacy in larger community contexts:

A radical recovery movement is now rising in America. That movement is flowing from the realization that addiction and its progeny of problems are visible everywhere, while recovery from addiction lies hidden. It is rising in the recognition that the stigma attached to AOD problems has increased in recent decades and has fueled the demedicalization and recriminalization of these problems. What started out as “zero tolerance” for drugs rapidly evolved into zero tolerance for people with AOD problems. It is in this regressive climate that a style of recovery is emerging that is radical in its scope (focus on environmental as well as personal transformation), radical in its inclusiveness (celebration of multiple pathways and styles of recovery), and radical in its synthesis of social responsibility and personal accountability. People in recovery are looking beyond their own addiction and recovery experiences to the broader social conditions within which AOD problems arise and are sustained. A radicalized vanguard of people in recovery is using personal transformation as a fulcrum for social change. They are living Gandhi’s challenge to become the change they wish to see in the world. Those who were once part of the problem are becoming part of the solution.

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I don’t get it

scott_pilgrim__noclue_getsit_by_nippey-d31sjjcYesterday, I read this, “we still don’t get addiction” article and was a little bemused.

The article presents an argument that addiction is a learning disorder and presents this as a controversial theory.

It’s not.

She also presents it as a theory that undercuts the ideas that addiction is a brain disease and that it’s a chronic disease.

It doesn’t.

Addiction is a disorder of learning. It’s also a disorder of motivation, a disorder of pleasure, a disorder of  memory, a disorder of stress responses and a disorder of choice. Environmental and social factors influence the development, course, severity and response to treatment. None of this is considered controversial.

Without much controversy, ASAM recently defined addiction as, “a primary, chronic disease of brain reward, motivation, memory and related circuitry.”

For years, I’ve advanced the idea that there are multiple mechanisms involved in addiction and that some addicts may have all of them, while people with  less severe substance use problems might have one or two. I’d also assume that we do not know of all the mechanisms.

Somehow, “we” still don’t get it.

The post is clearly meant to discredit most of the information we know and hear about addiction. Why? Especially on the basis of an idea that’s so widely accepted? I don’t get it.

I wasn’t the only person who noticed. DrugMonkey took exception with a post titled “Insinuations, misdirections, straw arguments and obsfucation in drug abuse journalism“.

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Moderation’s hard work for an alcoholic!

44685143AfterPartyChat has a really interesting first person piece from an alcoholic who tried Moderation Management.

Every now and then my addiction tries to convince me that I never truly hit bottom with alcohol and could probably drink moderately again one day. When that happens, I remind my disease that I’ve tried that, thanks. Before surrendering to 12-step recovery, I tried Moderation Management, a secular support group for “non-dependent problem drinkers.”

. . .

. . . would choose a certain number of drinks as their daily maximum. Ideally, we’d scale back our max each month until it stayed firmly in the green zone: four drinks for men, three for women. I could never manage a limit below five. The most annoying part of this wasn’t counting the physical drinks, it was figuring out how many drinks my drinks counted as. Some cocktails, and even some beers, contained enough alcohol for two or even three standard drinks. All in all, it was a lot more math than I’d bargained for.

. . . you couldn’t drink more than two days in a row. So if you wanted to party (moderately) on Friday and Saturday, both Thursday and Sunday were off limits. I struggled with the two-day rule even more than with the daily max. It completely changed my conception of what a weekend was.

Very interesting, and not written with an axe to grind. Read the whole thing here.

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chasing significance

Success-vs-SignificanceAn interesting study from journal Addictionon studies:

ABSTRACT
Background and Aims
The low reproducibility of findings within the scientific literature is a growing concern. This may be due to many findings being false positives which, in turn, can misdirect research effort and waste money.

Methods
We review factors that may contribute to poor study reproducibility and an excess of ‘significant’ findings within the published literature. Specifically, we consider the influence of current incentive structures and the impact of these on research practices.

Results
The prevalence of false positives within the literature may be attributable to a number of questionable research practices, ranging from the relatively innocent and minor (e.g. unplanned post-hoc tests) to the calculated and serious (e.g. fabrication of data). These practices may be driven by current incentive structures (e.g. pressure to publish), alongside the preferential emphasis placed by journals on novelty over veracity. There are a number of potential solutions to poor reproducibility, such as new publishing formats that emphasize the research question and study design, rather than the results obtained. This has the potential to minimize significance chasing and non-publication of null findings.

Conclusions
Significance chasing, questionable research practices and poor study reproducibility are the unfortunate consequence of a ‘publish or perish’ culture and a preference among journals for novel findings. It is likely that top–down change implemented by those with the ability to modify current incentive structure (e.g. funders and journals) will be required to address problems of poor reproducibility.

They offer an interesting solution:

Journals such as Cortex and Drug and Alcohol Dependence have introduced new manuscript submission formats that place the emphasis on the research question and study design, rather than the results obtained. Manuscripts (essentially protocols, containing the introduction, hypotheses, methods, analysis plan and sample size justification) are reviewed before data collection takes place, and judged on whether the results will be informative regardless of how they ultimately turn out. If acceptance-in-principle is offered, then the authors can conduct their study safe in the knowledge that, as long as they adhere to their plans, their results will eventually be published.

Deciding on whether or not to publish the results of a study before the results are known offers several important advantages. First, it ensures that publication depends on the importance of the research question being addressed, and the appropriateness of the methods chosen, rather than novelty and P-values. Secondly, it minimizes research practices that inflate the likelihood of false positives (e.g. ‘significance chasing’), given the requirement to adhere to pre-declared methods. Thirdly, the requirement for a priori power calculation to justify the sample size minimizes problems of low statistical power.

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“ceaseless reinvention leading to overlapping solutions”

0_A_winding_roadRead this last night on the brain’s “ceaseless reinvention leading to overlapping solutions” and it got me thinking about the long and challenging road ahead of us in developing a really solid understanding of addiction as a brain disease.

For centuries, neuroscience attempted to neatly assign labels to the various parts of the brain: this is the area for language, this one for morality, this for tool use, color detection, face recognition, and so on. This search for an orderly brain map started off as a viable endeavor, but turned out to be misguided.

The deep and beautiful trick of the brain is more interesting: it possesses multiple, overlapping ways of dealing with the world. It is a machine built of conflicting parts. It is a representative democracy that functions by competition among parties who all believe they know the right way to solve the problem.

As a result, we can get mad at ourselves, argue with ourselves, curse at ourselves and contract with ourselves. We can feel conflicted. These sorts of neural battles lie behind marital infidelity, relapses into addiction, cheating on diets, breaking of New Year’s resolutions—all situations in which some parts of a person want one thing and other parts another.

These are things which modern machines simply do not do. Your car cannot be conflicted about which way to turn: it has one steering wheel commanded by only one driver, and it follows directions without complaint. Brains, on the other hand, can be of two minds, and often many more. We don’t know whether to turn toward the cake or away from it, because there are several sets of hands on the steering wheel of behavior.

Take memory. Under normal circumstances, memories of daily events are consolidated by an area of the brain called the hippocampus. But in frightening situations—such as a car accident or a robbery—another area, the amygdala, also lays down memories along an independent, secondary memory track. Amygdala memories have a different quality to them: they are difficult to erase and they can return in “flash-bulb” fashion—a common description of rape victims and war veterans. In other words, there is more than one way to lay down memory. We’re not talking about memories of different events, but different memories of the same event. The unfolding story appears to be that there may be even more than two factions involved, all writing down information and later competing to tell the story. The unity of memory is an illusion.

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Asking the right questions in the right way

021-640x480Recovery Review directs our attention to a presentation by Jim Orford called Time to Ask the Right Questions in the Right Way: A New Direction for Addiction Treatment Research?. He suggests that comparisons between MET, CBT and TSF follow from us asking the wrong questions.

Here’s one of his suggestions.

Stop studying named techniques [CBT/MET/TSF] and focus instead on studying change processes and developing good, general addiction change theories

  • Need to change, can’t do it alone, ‘surrender’
  • Commitment, ‘self-liberation’
  • Incentives
  • Helper who is: credible, knowledgeable, efficient, concerned, working alliance
  • Communication, self-disclosure
  • Pledge, change statements
  • Social support for change
  • Coping with craving, negative emotions, etc.
  • Persistence
  • New identity

He offers the following tentative conclusions for this area:

Effective treatments have in common some basic process elements:

  • A knowledgeable, efficient, likeable and encouraging helper(s)
  • Who help(s) reinforce the feeling of need for change (e.g. encourage ‘discrepancy’)
  • Help(s) develop commitment to change (e.g. ‘pledges’, ‘change statements’)
  • Help(s) develop self-efficacy (e.g. ‘self liberation’, ‘seeing the benefits’)
  • And help(s) build social support for change

Under another suggestion he suggests that research look beyond primary treatment to include looking at the impact of:

  • What happened before
  • Entry procedures
  • The whole organisation
  • Mutual-help, faith communities and others
  • Families and social networks
  • The wider community

This is such a profound paradigm shift, but so self-evident when you see it described. An important question is what interests have us doing hundreds of studies on what are now, clearly, the the wrong questions?

He offers a suggestion. Our research is focused on what he describes as, “Time-limited Professionally Dominated Treatment”. What can we infer from that?

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Patient’s self-ratings? Bah, what do they know?

what-do-they-know_largeThree articles that caught my eye.

First, a meta-analysis on whether antidepressants improve overall wellness for young people. (One issue was that few studies have looked at overall wellness.)

Though limited by a small number of trials, our analyses suggest that antidepressants offer little to no benefit in improving overall well-being among depressed children and adolescents.

Another looks at attempts to see whether antidepressants reduce suicidality.

Based on measures taken pre- and post-treatment, the authors found that all treatments, including the pill placebo with clinical management, significantly reduced scores on both the interview and self-report measures of suicidality, with all having a medium effect size. According to the interview measure, interpersonal psychotherapy and antidepressant medication reduced suicidality more than the pill placebo with clinical management. No differences were found between treatments using the self-report measure.

Finally, an article that suggests that electronic health records and real world data are going to have a significant impact on drug development. I don’t question it, but it’s a lot easier for me to see this having major impact on evaluating drugs that have been approved and in use with patients.

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Dopey, Boozy, Smoky—and Stupid

Kleiman's recent book on marijuana legalization. There's something in it to make everyone mad.

Kleiman’s recent book on marijuana legalization. There’s something in it to make everyone mad.

This week’s Throwback Sunday post focuses on a 2007 policy article by Mark Kleiman. In 2013, Kleiman was selected as the project leader to write Washington State’s marijuana regulations after the drug was decriminalized through a ballot initiative.

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The National Interest has a lengthy article on drug policy by Mark A.R. Kleiman. I disagree with several of his points but this is exactly the kind of thoughtful contribution that the American drug policy debate needs more of.

I tend to see his perspective as hyper-rational (Possibly to balance the moral panic of drug crusaders and fetishization of drug culture by many legalization advocates.) and somewhat removed from both the suffering of addiction and the radical transformation that full recovery offers. I think he risks reducing policy issues to an accounting exercise but he expresses strong, well-informed opinions without and ideological ax to grind (Although there clear Libertarian themes.) and does so without characterizing and dismissing people who think differently.

After outlining the sad state of American drug policy he says:

These are depressing facts that cry out for a radical reform to solve the drug problem once and for all. But the first step toward achieving less awful results is accepting that there is no one “solution” to the drug problem, for essentially three reasons. First, the potential for drug abuse is built into the human brain. Left to their own devices, and subject to the sway of fashion and the blandishments of advertising, many people will wind up ruining their lives and the lives of those around them by falling under the spell of one drug or another. Second, any laws—prohibitions, regulations or taxes—stringent enough to substantially reduce the number of addicts will be defied and evaded, and those who use drugs in defiance of the laws will generally wind up poorer, sicker and more likely to be criminally active than they would otherwise have been. Third, drug law enforcement must be intrusive if it is to be effective, and enterprises created for the expressed purpose of breaking the law naturally tend toward violence because they cannot rely on courts to settle disputes or police to protect them from robbery or extortion.

Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.

But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.

The reforms needed to achieve these ambitious goals are radical rather than incremental. But they are not simple, or all of a piece, or in any one of the directions defined by current arguments around American dinner tables, on American editorial pages or in American legislative chambers. The conventional division of drug programs into enforcement, prevention and treatment conceals more than it reveals. So does the standard political line between punitive drug policy “hawks” and service-oriented drug policy “doves.” Neither side is consistently right; some potential improvements in drug policy are hawkish, some are dovish, and some are neither.

I disagree with the hawk vs. doves dichotomy. The service-oriented doves are really divided into at least two camps. An older, more deeply entrenched group but shrinking group of treatment professionals who might be dovish relative to hawks, but generally support some form of prohibition. Then there is a newer group of doves who aren’t all that service-oriented but are more radically dovish, advocating more radical decriminalization.

He offers five principles to guide policy decisions:

First, the overarching goal of policyshould be tominimize the damage done to drug users and to others from the risks of the drugs themselves (toxicity, intoxicated behavior and addiction) and from control measures and efforts to evade them.That implies a second principle: No harm, no foul. Mere use of an abusable drug does not constitute a problem demanding public intervention. “Drug users” are not the enemy, and a achieving a “drug-free society” is not only impossible but unnecessary to achieve the purposes for which the drug laws were enacted.

Third, one size does not fit all: Drugs, users, markets and dealers all differ, and policies need to be as differentiated as the situations they address.

Fourth, all drug control policies, including enforcement, should be subjected to cost-benefit tests: We should act only when we can do more good than harm, not merely to express our righteousness. Since lawbreakers and their families are human beings, their suffering counts, too: Arrests and prison terms are costs, not benefits, of policy. Policymakers should learn from their mistakes and abandon unsuccessful efforts, which means that organizational learning must be built into organizational design. In drug policy as in most other policy arenas, feedback is the breakfast of champions.

Fifth, in discussing programmatic innovations we should focus on programs that can be scaled up sufficiently to put a substantial dent in major problems. With drug abusers numbered in the millions, programs that affect only thousands are barely worth thinking about unless they show growth potential.

Finally, he offers an agenda for policy change. I doubt I could ever comfortably endorse some of these. Others, I find myself resisting, but in the context of radical change (rather than incremental), they may be more acceptable.

  • Don’t fill prisons with ordinary dealers.
  • Lock up dealers based on nastiness, not on volume.
  • Pressure drug-using offenders to stop.
  • Break up flagrant drug markets using low-arrest crackdowns.
  • Deny alcohol to problem drinkers.
  • Raise the tax on alcohol, especially beer.
  • Eliminate the minimum drinking age.
  • Prevent drug dealing among kids.
  • Say more than “No.”
  • Don’t rely on DARE.
  • Encourage less risky forms of nicotine use.
  • Let pot-smokers grow their own.
  • Encourage problem drug users to quit without formal treatment.
  • Expand opiate maintenance.
  • Work on immunotherapies.
  • Get drug enforcement out of the way of pain relief.
  • Create a regulatory framework for performance-enhancing chemicals.
  • Figure out what hallucinogens are good for, and don’t let the drug laws interfere with religious freedom.
  • Stop sacrificing foreign policy and human rights objectives to drug control.

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